Many Missing Pieces

Despite the threat that untreated substance abuse presents to both individual and public health, significant barriers to treatment remain.

Lack of Resources

23.1 million persons aged 12 or older needed treatment for an alcohol or substance use disorder, but only 2.6 received treatment at a specialized addiction facility. (https://www.mentalhelp.net/articles/addiction-statistics-how-big-of-a-problem-is-it/)


  • Limited hours (many shelters are closed during the day)
  • Dependence on volunteers
  • Limited access to less common medications
  • Limited specialty and ancillary services (e.g., podiatry and dental care)
  • Insufficient resources to perform systematic screening
  • Difficulty obtaining liability insurance and medical malpractice insurance (especially critical when volunteers are retired physicians who do not have their own malpractice insurance)
  • Resource limitations often dictate long waiting lists, lack of transportation, and lack of documentation.

Institutional Barriers

Federal Restrictions

  • Much public policy has favored a punitive approach to substance abuse, even though medical and public health experts agree that treatment and prevention are more effective.
  • Few federal substance abuse treatment and prevention programs target funds specifically to the homeless population.
  • Health, mental health, and substance abuse have traditionally had separate funding streams, even though all three can interact with each other. This often blocks the delivery of services to people with multiple diagnoses.


  • A comprehensive, cohesive system of services is often lacking. Even those programs that have strong ties with hospitals seldom network with programs that serve the mentally ill or substance abusers.
  • Institutions providing for the homeless and addicted vary widely in terms of history, funding levels, resources, and support, often resulting in an ad hoc administrative approach with crisis response taking precedent over well thought out plans.
  • Certain services, such as case management, tend to be provided directly by salaried staff while other services, such as clinic operations, are provided by contractors.
  • Case management is often ill-defined and the role of the case manager inadequately described.
  • Effective case management relies on accurate feedback from the facilities personnel to which clients are referred, but such feedback is not always forthcoming.
  • Discharge planning is difficult and complex. The lack of a full range of community-based placements can prevent clients, patients, and former inmates from reaching their potential.

Lack of Insurance

  • The biggest factor preventing people from being treated are the high costs and lack of insurance (NASADAD). The lack of insurance often make substance abuse treatment unattainable for the homeless.


  • Many programs offering treatment for mental illness don’t accept people with substance abuse disorders. And many programs offering treatment for the homeless with SUDs do not treat people with mental illnesses.

Client Challenges

Treatment Complexities

  • Homeless people are more susceptible to certain diseases, have greater difficulty getting health care, and are harder to treat than other people, all because they lack a home.
  • Many of the adaptive, creative responses that homeless people develop for coping on the street may work against their being moved into a domiciled situation. The change may be overwhelming and frightening for them to contemplate.
  • The homeless may find it difficult to keep and take medications in a timely fashion while living on the street.
  • In addition to physical and mental health problems, homeless people often experience drug or alcohol abuse as well. Any health care program for the homeless should expect 25 to 40 percent of its adult patients to experience serious alcohol or drug abuse problems.
  • Many of the homeless are estranged from families and friends. Without a social support network, recovering from a substance addiction can be very difficult.
  • Alienation and isolation often cause (and sometimes is caused by) a limited capacity to establish supportive relationships with other people.
  • Difficulties in establishing and maintaining relationships can militate against the development of cooperation with health care providers and may be an important factor in explaining what is often inaccurately described as a “lack of motivation.”
  • Even if they do break their addictions, homeless people may have difficulty remaining sober while living on the streets where substances are so widely used. For an alcoholic trying to stay sober, for example, a homeless existence may present too many opportunities for drinking.
  • Neuroleptic medications, prescribed for a schizophrenic illness, may make the homeless too drowsy and interfere with the alertness need to guard against the dangers present when living on the streets.

Widely Differing Needs

  • Many standard forms of treatment assume that the patient has a home; when that is not true, treatment can be extraordinarily difficult.
  • Substance abusers who are homeless have different needs than those who are housed and require different programs to address those needs.
  • Homeless people with SUDs and mental illness face more obstacles and are at greater risk for violence and victimization.
  • Because substance abuse is both a cause and a result of homelessness, both issues need to be addressed simultaneously, but that’s not always easy to do.
  • Many homeless people with physical disabilities, mental disabilities, or both who cannot live independently require supportive living settings.
  • Programs designed to treat individuals often find that providing the same services to families can present a very different set of problems.
  • Programs that specifically serve homeless families do not exist in the numbers needed, especially in light of reports that this is the fastest growing subpopulation among the homeless.
  • The lack of resources devoted to homeless youth often causes emergency shelters to become 30- to 45-day warehouses for adolescents with no other place to go.
  • Patients with AIDS can become increasingly disabled as the disease progresses, required additional forms of housing with varying levels of physical care, including skilled nursing facilities and hospices. The alternative, hospitalization, can be extremely expensive.

Client Attitude

  • In addition to distrust of authority, many homeless people are disenchanted with health and mental health care providers. Some have had bad experiences with medications, hospitals, doctors, and other human service professionals and are leery of further involvement.
  • Some clients think drug and alcohol use is necessary to be accepted among the homeless.
  • Survival may be more Important to many homeless people than personal growth.
  • Finding food and shelter can take a higher priority than drug counseling.
  • 95% of those who need treatment for alcoholism do not feel they need it. (https://www.addictioncenter.com/addiction/addiction-statistics/)
  • “Rescue Missions” are sometimes avoided by homeless people who object to religious teaching.

Staffing Challenges

The problems presented by the homeless and addicted can overwhelm even the best trained, most experienced workers.


  • Low salaries, long hours, and a lack of available opportunities for continuing education and training are considerable barriers to recruiting and retaining qualified staff.

Social Stigma

  • Society can stigmatize staff as well as the homeless they serve.
  • Lack of respect for their profession can discourage counselors from entering and remaining in the field.


  • Poor funding, heavy caseloads, a lack of time for one-on-one care, excessive paperwork, and other bureaucratic demands can exhaust even the most dedicated.
  • The disparity between needed and available services can frustrate those on the front lines, particularly substance abuse treatment counselors.

Contracted Staff

  • Staff contracted by a major health care agency may divide their loyalty between their employer and their agency. Such contract agencies often have different personnel policies regarding holidays, vacations, pay scale, opportunities for advancement, staff development programs, and so on. These differences can negatively affect the morale of team members who work for different employers.

Geographical Challenges

Urban Areas

  • Treatment needs in urban areas often outweigh the service availability.
  • Substance abuse treatment in urban areas can be complicated by a lack of funding and the challenges of working with heterogeneous clients.
  • Services focused in a downtown area where the homeless are concentrated can effectively exclude large numbers of the homeless residing outside the catchment area.
  • Conversely, the effort to cover as broad an area as possible can result in service delays because of the time spent in transit.

Rural Areas

  • Many concerns once thought to be specifically urban, such as concentrated poverty and availability of drugs, are no longer endemic only to urban areas.
  • Rural areas continue to be disproportionately disadvantaged with a lack of basic services and underutilization of available services when compared to urban contexts.
  • Exacerbating the problem of fewer facilities, rural clients are more geographically dispersed with fewer public transportation options.
  • The fact that shorter travel distances contributes to longer stays and greater completion rates has unfortunate implications for rural counselors and clients.
  • Compared to urban areas, rural areas often lack options for specialty substance abuse treatment programs such as those tailored to women and racial minorities; this can discourage treatment utilization among underserved, at-risk populations.
  • Treatment-seeking in rural areas may also mean a lack of anonymity since there are fewer facilities and a higher probability of recognition in group-based meetings.

Mobile Challenges

  • The informality of shelters and soup kitchens may seem less threatening and more inviting to the homeless, but also tend to be less stable. Soup kitchens may close down for a week or a month due to lack of funding or volunteers. Finding space with access to running water can be difficult. Soup kitchens and meal programs are often open only briefly in the middle of the day or in the evening. Programs for the homeless sometimes close in April and don’t reopen till November. The resulting fluctuations in attendance, patient flow and hours of operation can make staffing challenging.

Mental Illness Complications

  • 6.8 million people with addictions also have some form of mental illness. Those untreated often use street drugs as a form of self-medication.
  • The mentally ill often experience extreme poverty, a lack of insight into their psychiatric problems, distaste for psychiatric treatment, and a complex mix of needs.
  • Effective treatment may require rehabilitation programs, a variety of supportive services and specialized forms of housing, ranging from independent living quarters with minimal supervision to round-the-clock supervision in a community residence.
  • Homeless people who experience chronic mental illness seldom find the array of comprehensive services they need. As a consequence, the care given by clinicians tends to be limited.